Report No: AUS1920
Lao People’s Democratic Republic
Maternal Health, Child Health
& Nutrition in Lao PDR
Evidence from a Household Survey
in Six Central and Southern Provinces
June 2013
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MATERNAL HEALTH, CHILD HEALTH, AND NUTRITION IN LAO PDR:
EVIDENCE FROM A SURVEY IN SIX CENTRAL AND SOUTHERN PROVINCES1
EXECUTIVE SUMMARY
Lao PDR has made dramatic improvements in some areas. Unsurprisingly, physical access to health
population-level health outcomes over the past facilities was difficult: the mean distance to
several decades. For example, life expectancy has the nearest health center and hospital for
increased from 46 years in 1970 to 67 years in 2011. households in the sample was 6 km and 34 km
However, the country still has some of the worst ma- respectively. Apart from physical access, financial
ternal health, child health, and nutrition indicators barriers are also important and were in fact the
in the region. The under-five mortality rate is 42 per most frequently reported constraint to the utilization
1,000 live births, while the maternal mortality rate is of health services (by 45% of respondents). This
470 per 100,000 live births. Nutrition indicators are relates to the low coverage of health insurance
also alarming, with 32% and 48% of under-fives are schemes: less than 4% of households were covered
underweight and stunted respectively. With its high by any such scheme.
prevalence of undernutrition, Lao PDR is an
outlier when contrasted with regional comparators, Given this context, the utilization of all the basic
even after accounting for national income. maternal health services – antenatal care visits,
Recently introduced strategies, such as the free institutional deliveries, and postnatal care visits
maternal and child health (MCH) policy and the – was extremely low. Only 40% of women with
National Nutrition Strategy, aim to address these a child under two years reported at least one
issues and to attain health-related MDGs by antenatal care visit; only 14% of births occurred at
2015. Against this backdrop, this report presents
findings from a household, village, and health
center survey of largely rural communities in six
any health facility, and postnatal care visits were ex-
ceedingly rare (2%). Even where utilization occurred,
this was often inadequate from both a demand-side
1
central and southern provinces of Lao PDR and supply-side perspective. For example, on the
conducted in 2010. These communities are the target demand-side, antenatal care visits were often too late
of various pilot interventions aimed at addressing in the pregnancy (less than a third had their first visit
these poor health-related MDG indicators, for which during the recommended first trimester) and only
this survey was designed to contextualize, inform, about half went for the recommended minimum
and evaluate. of four antenatal care visits. On the supply-side health
facilities lacked important commodities like iron
The household survey, which focused on rural orfolate supplements. Importantly, utilization
households with at least one living child under varied along key demographic characteristics: for
two, confirms the largely rural nature of the sample example, institutional delivery rates were much
compared with the national population, with a higher higher in urban communities (30%) compared with
proportion of non-Lao Tai ethnic groups, larger rural communities without a road (6%) and were
household sizes, and a predominance of agricultural also much higher among mother’s with secondary
activities as the primary occupation. Indeed, more education (30%) compared with mother’s with no
than 80% of households were resident in rural education (7%).
1
This report was written by a team consisting of Chantelle Boudreaux, Ajay Tandon, and Wei Aun Yap; Data analysis was conducted by Ajay
Tandon, Wei Aun Yap, Laurence Lannes, and Chantelle Boudreax; The survey was designed by Magnus Lindelow, Chantelle Boudreaux, and
Robert McLaughlin; IndoChina Research Ltd. collected the data; Valuable inputs were provided by Phetdara Chanthala, Sophavanh Thitsy,
Anna Lorenza-Pigazzini, Somchit Akkhavong, and Khamseng Philavong; The team would like to thank Yi-Kyoung Lee and Darren Dorkin
for excellent comments made on a previous version of the report.
Utilization of preventative child health services was only 50% of respondents washed their hands
also extremely low, with only 9% of children under before cooking and only 9% did so before feeding
two taken for routine well-baby check-ups. For this the baby. The survey also notes that 15% of children
reason, it is unsurprising that coverage of under two had an episode of diarrhea in the
immunizations was also poor, with only 26% of last two weeks prior to the survey. Symptomatic
children aged 12-23 months having received all episodes of diarrhea are not the only nutritionally
the Expanded Program on Immunizations (EPI) relevant manifestation of fecal-oral contamination.
vaccines. A sharp decline is noted between the first Environmental enteropathy, which is intestinal
dose of vaccinations (83% for DPT1 and 83% for damage caused by contaminated water, toxins,
Polio1) compared with the second dose of antigens, nutrient deficiencies, and infections,
vaccinations (41% for DPT2 and 45% for Polio2) thus is both a contributor to malnutrition (through
indicating substantial loss to follow-up. malabsorption and maldigestion), and a result
of malnutrition. As 77% of households in this
Dietary diversity was limited with almost all families sample in the lacked a toilet, the environment
consuming grains and vegetables but less than half of the whole community – not just individual
consuming any meat or fish. Household diets lacked households who lack sanitation facilities – would
both Vitamin A-and iron-rich foods. Furthermore, only be presumed to be contaminated. Hence, in-
40% of children under two benefitted from timely terventions aimed at arresting this downward
initiation of breastfeeding within one hour of delivery. spiral of child undernutrition should be aimed at
Anthropometric measurements of children under the whole community, including both adults and
two further confirm the severity of undernutrition in children, rather than focusing only on nutritionally
these communities. More than a third (36%) of these vulnerable children.
children were stunted and 13% were severely stunted.
Almost one-third (31%) of these children were The results from this survey thus shed light on
underweight and 11% were severely underweight. what it would take to attain the health-related
2 Importantly, undernutrition varied along key de-
mographic parameters and household charac-
teristics, but remained substantial even in rela-
MDGs. In order to improve the level and equity of
maternal and child health indicators, interventions
would need to address numerous demand-side
tively wealthy and better-educated households. barriers, including physical access barriers, financial
For example, the prevalence of stunting varied barriers, and cultural, linguistic, and educational
from 43% among the poorest economic quintile to barriers. In addition to demand-side measures
24% among the richest; and also varied from 43% aimed at increasing utilization, it is likely that more
among children whose mother had no education investments are required on the supply-side to insure
to 23% among children whose mother had lower high-quality services are available by adequately-
secondary education. Children whose household trained staff and adequately equipped and stocked-
lacked access to a toilet were also associated with health facilities. With regards to nutrition indicators,
higher rates of stunting (39%) than children with a cross-sectoral approach is required, intervening not
such access (26%). just within the health sector (for example, in encour-
aging appropriate breastfeeding and complemen-
These variations in the prevalence of undernutrition tary feeding practices, providing micronutrients to
are further contextualized by water and sanitation both mothers and children, and promoting hygienic
indicators generated from this survey. Only 23% practices) but also in sectors beyond health. Inter-
of households had access to a sanitation facility ventions which promote access and use of improved
and only 40% of households had access to drinking water supply and hygienic sanitation facili-
improved drinking water sources. Behavioral ties are needed to reduce the prevalence of diarrhea,
indicators are also a concern as even though most while interventions in the agriculture sector will help
households had a specific place to wash hands, to address food security and dietary diversity issues.
INTRODUCTION
Despite being on-track on the child- and PDR. The information in this report localizes MCH &
maternal-health MDGs, Lao PDR continues to nutrition-related information that are typical for
have some of the worst maternal and child health sampled catchment areas of selected health centers
(MCH) and nutrition outcome indicators, both in six central and southern provinces of the country.2
globally as well as in the East Asia and Pacific (EAP) In addition, the report summarizes data on service
region. Underlying poor levels of MCH and nutrition availability and readiness of health centers in terms
outcomes are poor quality and low levels of cov- of their ability to provide key MCH & nutrition-related
erage of key MCH utilization indicators such as services.
antenatal care (ANC), skilled birth attendance, as well
as measles and DPT immunization rates. Physical,
financial, and cultural barriers help explain low
coverage rates from a demand-side perspective.
Poor training of health workers, service readiness
deficiencies, and generally inadequate quality of care
are some of the key challenges from a supply-side
perspective.
In recognition of these challenges, the Govern-
ment of Lao PDR has recently adopted a health
sector reform strategy with the overarching
objectives of: (i) attainment of health-related MDGs
by 2015; and (ii) achievement of universal health
coverage (UHC) by 2025. Key aspects of the reform
agenda include increasing domestically-sourced
government financing for health, ensuring adequate
3
availability of skilled and motivated health workers,
improving access to essential medicines and
technology, and bolstering grass-root level service
delivery efforts, among others.
This report presents results from a household,
village, and facility survey on MCH & nutrition
in mostly rural areas of six central and southern
provinces of Lao PDR. Effective implementation
of the government’s health sector reform agenda will
require timely and frequently-updated information
on the underlying factors determining the low levels
of key MCH and nutrition-related outcomes and,
in looking forward, what the impact of policy
interventions on these outcomes has been. In light of
helping provide evidence for informing policy-
making and implementation, this report provides
some key baseline information on MCH- and nutri-
tion related outcomes and their correlates in Lao
Photo by Bart Verweij/2013
2
The analysis in this report complements recently compiled national and provincial-level information on MCH & nutrition-related data
collected in 2011 as part of the Lao Social Indicators Survey (LSIS).
BACKGROUND AND CONTEXT
Lao PDR has made steady and significant progress day, PPP) have declined from 56% of the population
on several key population health outcomes over in 1992 to 34% in 2008. In the social sectors, adult lit-
the past few decades. Life expectancy has steadily eracy rates rose from 60% to 73% between 1995 and
increased to almost 67 years in 2011, up from 54 years 2005, while the fertility rate (total births per woman)
in 1990 (Figure 1). The under-five mortality rate has declined dramatically from 6.2 in 1990 to 2.7 in 2010.
also declined steadily from 148 per 1,000 live births In the health sector, preventative strategies – includ-
in 1990 to 42 per 1,000 live births in 2011 (Figure ing expanding access to family planning, immuniza-
1). At current trends, Lao PDR is projected to meet tions, and the reduction of anemia – have been im-
the child- and maternal-health related Millennium portant contributors to the improvements seen in
Development Goals (MDGs). Under-five and infant child and maternal health indicators.
mortality rates in Lao PDR are about average, adult
mortality rates are better than average relative to Despite notable progress in health on some fronts,
GDP per capita in the newly reclassified lower-middle considerable challenges remain. Despite being
income country. on-track on the child- and maternal-health MDGs,
Lao PDR continues to have some of the worst MCH
Population health indicators for Lao PDR, 1990-2011 and nutrition outcome indicators, both globally
as well as in the East Asia and Pacific (EAP) region.
70
100 120 140
Although there is some uncertainty regarding exact
numerical values, WHO/UNICEF/UNFPA/World Bank
(2012) estimate that, at 470 per 100,000 live births,
65
Lao PDR’s maternal mortality ratio (MMR) is among
Life expectancy
80
the highest in the world, and is almost double that of
4 neighboring Cambodia and almost eight times that
60
60
of Vietnam (Table 1).3 More recent estimates from
LSIS data indicate an MMR of 357 per 100,000 live
births. About a third of all children under five remain
40
55
underweight in the country. At current trends, Lao
1990 2000 2010
Year PDR is off-track on the nutrition MDG, and there are
Source: WDI
Note: y-scale logged significant urban-rural, socio-economic, geographic,
and ethnic-group related inequalities in health out-
Figure 1: Key population health indicators for Lao PDR: 1990-2011 comes. Underlying poor levels of MCH and nutri-
tion outcomes are poor quality and low levels of
The decades between 1990 and 2010 have been a coverage of key MCH utilization indicators such as
time of significant economic growth for Lao PDR, antenatal care (ANC) and skilled birth attendance.
following economic liberalization reforms which Births attended by skilled personnel only increased
began in 1986. Major national infrastructure from14% to 17% between 1994 and 1999,4 while, de-
initiatives were active during this period: the spite improvements over time, immunizations rates
time period saw the upgrading of highway 13 including measles and DPT remain low relative
and a large rural electrification initiative. Poverty to neighboring countries (Table 1).
headcounts (based on a poverty line of US$ 1.25 per
3
WHO/UNICEF/UNFPA/World Bank (2012), Trends in Maternal Mortality: 1990-2010, Geneva: World Health Organization.
4
Eckermann, Liz. “Finding A ’safe’ place on the Risk Continuum: a Case Study of Pregnancy and Birthing in Lao PDR.” Health Sociology
Review 15, no. 4 (2006): 374–386.
Table 1: Key MDG and other indicators for Lao PDR and comparators
Country GNI per MMR At Skilled Prevalence Prevalence Under-five Measles DPT3
capita per least 1 birth of of mortality rate immunization immunization
(2011) 100,000 ANC attendance underweight stunting per 1,000 live rate rate
live visit children<5 children<5 births
births (2011)
(2010)
Cambodia $820 250 69% 57% 29% 41% 43 85% 87%
China $4,940 37 92% 98% 4% 9% 15 95% 95%
Indonesia $2,940 220 93% 79% 21% 39% 32 82% 78%
Lao PDR $1,130 470 35% 29% 32% 48% 42 64% 74%
PNG $1,480 230 79% 53% 18% 44% 58 58% 59%
Philippines $2,210 99 91% 62% 21% 32% 25 91% 88%
Thailand $4,440 48 99% 98% 7% 16% 12 97% 99%
Timor-Leste $2,220 300 84% 29% 45% 58% 54 64% 69%
Vietnam $1,270 59 91% 88% 21% 31% 22 93% 94%
East Asia & $3,257 140 87% 81% 17% 31% 30 82% 84%
Pacific
Lower-Middle $2,371 215 86% 79% 15% 31% 49 83% 85%
Income
Countries
5
Lower-Income $553 452 76% 53% 23% 40% 99 75% 77%
Countries
Note: Unweighted averages for country groupings; average or latest available year 2005-2011 where year not noted.
In recognition of these challenges, the Lao PDR Scaling-Up Nutrition (SUN) initiative, and a dedicated
government has recently adopted a health sec- national nutrition center housed within the Ministry
tor reform strategy with the overarching objectives of Health has recently opened. The 7th Nation-
of: (i) attainment of health-related MDGs by 2015; al Socioeconomic Development Plan highlights
and (ii) achievement of universal health coverage “sustainable health financing” as one of the priority
(UHC) by 2025. Key aspects of the reform agenda in- areas for 2011-2015, with a focus on increasing
clude increasing domestically-sourced government the government budget for health, expanding
financing for health, ensuring adequate availability prepayment schemes, and developing mechanisms
of skilled and motivated health workers, improving for ensuring the poor have access to health services.6
access to essential medicines and technology, and The government has made a commitment to increase
bolstering grass-root level service delivery efforts, health’s share of the government budget to 9%, up
among others.5 In addition, Lao PDR has recently from current allocations that have been in the 3%
signed on to become an “early riser” in the global range.7
5
Ministry of Health (2012), National Health Sector Reform Strategy: 2013-2025, Vientiane: Ministry of Health.
6
Ministry of Planning and Investment (2011), The Seventh Five-year National Socio-Economic Development Plan (2011-2015), Vientiane:
Ministry of Planning and Investment, Government of Lao PDR.
7
Lindelow et al, World Bank (2011), “Government Spending on Health in Lao PDR: Evidence and Issues,” World Bank, Washington, DC.
In order to improve the utilization of MCH services,
of micronutrients by community-based distributors
and to reduce the burden of associated out-of-
are also included. These interventions are intended
pocket payments, the government is in the process
to increase the demand for and utilization of
of beginning the implementation of a Ministerial
basic health services. The first intervention is
decree aimed at incentivizing the supply as well as
also intended to improve financial protection
demand of MCH and other related services at all public
from catastrophic health expenditure. Both
health facilities. The decree - referred to as the “free
interventions contain nutrition-sensitive and
MCH policy” - is a form of results-based financing
nutrition-specific interventions on enabling
(RBF) that will remove user fees and charges for
the distribution of micronutrients, encouraging
medicines, provide beneficiaries with small incentive
appropriate exclusive breastfeeding and
payments, and reimburse health facilities for
complementary feeding, and hygiene and
provision of MCH-related care. The free MCH policy
sanitation messaging. The survey described in
builds on the relatively positive experience of several
this report was conceived both to inform the
smaller-scale donor-financed pilots that have
implementation of these interventions and to
implemented similar interventions in selected regions
act as a baseline for an embedded impact and
of Lao PDR over the past few years.8 In addition, the
process evaluation. The complementary endline
government will soon complete the piloting of the
survey is currently in progress in the same panel
Community Nutrition Project, which utilized village
of villages and health centers.
health volunteers, village heads, and Lao Women’s
Union representatives to provide key messaging
related to MCH and nutrition in addition to providing Given this backdrop, this report presents results
conditional cash transfers to mothers and pregnant from a household, village, and facility survey on
women for the use of services (Box 1). MCH and nutrition in mostly rural areas of six
central and southern provinces of Lao PDR.
6 Box 1: The Community Nutrition Project (CNP)
The Community Nutrition Project was conceived
Effective implementation of the government’s
health sector reform agenda will require timely and
frequently-updated information on the underlying
as an emergency pilot project to protect and factors determining the low levels of key MCH and
improve nutritional outcomes in the context of high nutrition-related outcomes and, in looking forward,
and volatile food prices. It aimed to expand the what the impact of policy interventions on these
utilization of key health services, which may outcomes has been. In helping to provide evidence
be under pressure due to food price and other for informing policy-making and implementation,
macro shocks. The project piloted two key this report provides some key baseline information
demand-side interventions: (1) a conditional cash on MCH- and nutrition-related outcomes and their
transfer (CCT) scheme for all pregnant women and correlates in Lao PDR.
mothers of children under two, conditional on
utilizing key maternal and child health services The remainder of the report is organized as follows:
such as antenatal visits, facility-based deliveries, the next section provides a brief overview of the
and regular child growth monitoring visits; socio-economic characteristics of households
and (2) a community-based health and nutrition included in the survey sample. The report then
behavior change program, which trains village highlights key findings related to general nutrition
facilitators to conduct regular village meetings and health indicators, followed by outcomes and
where health and nutritional messages are correlates related to MCH and nutrition outcome
discussed. Additional activities for training and and coverage indicators. The report concludes with
supervising health workers, and the distribution a summary overview and some discussion of policy
implications.
8
Pilots include the World Bank-supported Health Services Improvement Project (HSIP) as well as projects financed by Lao-Lux, WHO, and
Medicine du Monde.
SOCIO-ECONOMIC CHARACTERIS-
TICS OF HOUSEHOLDS
Using a multi-level cluster sampling meth- were Hmong-Mien (Table 2). As can be seen in Table
odology, the survey sampled 2,741 house- 2, the proportion of non-Lao-Tai ethnic groups in the
holds living in 193 villages across 21 survey was higher than in the national population,
high-priority and/or poor districts in the prov- again reflecting the greater proportion of rural and
inces of Borikhamxay, Khammuane, Savan- remote communities included in the sample.
nakhet, Saravane, Champasack, and Attapeu.
The data span the catchment areas of 38 health
centers in these six provinces.9 These included both
health centers and villages which were the intended
target of CNP and matched control health centers
and villages. Figure 2 shows the location of sampled
districts, villages, and health centers. The sampled
villages cover a population of approximately 112,000,
from a national population of 6.2 million10, in 21
out of 142 districts, and 6 out of 17 provinces. The
household data, which is the main focus of this
report, is complemented by facility audits and
questionnaires conducted at each of the 38 health
centers and surveys conducted at the village level.
At health centers, facility personnel answered
questions, while village heads were the respondents
for the village questionnaire. This survey focuses on
the results of the household survey, for which mothers
7
or the primary caretaker was interviewed in randomly
selected households having at least one living child
less than two years of age.
80.4% of respondent households lived in rural ar-
eas (42.6% in rural areas with road access plus 37.8%
in rural areas without road access) and the remaining
19.6% lived in urban areas. This contrasts with the
national population, where 67% of the population is
rural.11 The average household size among the sample
was 6.4, higher than the national average of 5.2, and
95.0% of households were headed by men.12 A slight
majority (51%) of household heads were Lao-Tai,
followed by 44% who were Mon-Khmer and 3% who
Photo by Bart Verweij/2013
9
The survey was conducted in April-June 2010 to provide baseline information for the World Bank and European Union-financed Com-
munity Nutrition Project currently being implemented by the Department of Hygiene and Prevention of the Ministry of Health of the
Government of Lao PDR; The full list of the 38 health centers is reported in Annex A.
10
WDI 2010
11
WDI 2010
12
Ministry of Health and Lao Statistics Bureau (2012), Lao Social Indicator Survey 2011-2012, Vientiane, Lao PDR: Ministry of Health and
Lao Statistics Bureau.
8
Figure 2: Survey map: sampled districts (orange), villages (blue dots), and health centers (red crosses)
Table 2: Distribution of households by ethno-linguistic group13
Ethno-linguistic group Percent of sample Percent of Lao PDR national population
Lao-Tai 51% 68%
Mon-Khmer 44% 22%
Hmong-Mien 3% 7%
Chinese-Tibetan 0.2% 3%
Other 2% 0.6%
Total 100% 100%
Among individuals aged 14 and above, 87% are only primary education. About 18% of household
reported as being self-employed in agriculture. heads had completed secondary schooling, with
In the same age group, 3% are as reported to be the remaining 7% having had some post-secondary
students, 4% are employed by the public sector, education. Respondent mothers (those that had
and 3% are retired, sick, or disabled. In 36% of given birth most recently in the household) had even
households, the head had no formal education lower educational attainment levels, with more than
whatsoever; and a similar proportion had completed half reporting no schooling (Figure 3).
Educational attainment
9
Household head Respondent mother
50
50
40
40
Percent
Percent
30
30
20
20
10
10
0
0
n
y
y
y
er
n
y
y
y
er
ar
r
r
ar
r
r
tio
tio
da
da
da
da
gh
gh
im
im
ca
ca
n
on
n
on
hi
hi
Pr
Pr
co
co
u
u
nd
nd
ec
ec
ed
ed
se
se
rs
rs
ya
ya
No
No
er
er
pe
pe
r
r
w
w
da
da
Up
Up
Lo
Lo
n
n
co
co
e
e
t-s
t-s
s
s
Po
Po
Source: CNP Baseline Survey
Figure 3: Educational attainment of household heads and respondent mothers
13
The national ethnic-group distribution is from the Lao Social Indicator Survey report.
Almost all (98%) households reported owning washing their hands after using the toilet and 17%
their own home. Most households accessed drinking reported washing their hands after cleaning the
water using a protected well, followed by surface baby’s bottom. Where the place and process of hand
water, and an unprotected well (Table 3). In all, about washing was observed, the following items were
40% of households had access to improved drinking observed: bar soap (39%), detergent (24%), liquid
water sources.14 More than three-fourths of the soap (3.2%), and ash/mud/sand (0.11%). Observations
households reported sometimes boiling the water of respondent hand washing note that water was
before drinking to make it safer, although this was frequently (93%) used but soap was less frequently
consistently practiced by less than half of those (45%) used. Only 89% washed both hands, rubbed
reporting boiling the water. About 77% of households their hands at three times (75%), and dried it with
did not have a sanitation facility; the remaining a clean cloth or allowed it to air dry (45%).
reported having a flush toilet (22%) or a pit latrine
(0.8%) (Table 3). Among households which reported Only 41% of households in the sample reported
having a toilet, most (93%) appeared to have been having access to electricity from the grid. About
used, and 83% were very clean or moderately clean. 11% reported using electricity from generators or
Despite the relatively higher availability of toilets, few batteries, and 36% reported using kerosene lamps as
households used them to dispose of child waste. More their primary source of light. Most (>90%) households
than 80% of families left child feces in the open (54%) in the sample had wood and bamboo flooring and
or in a ditch or drain (27%). Slightly less than 20% of walls.
families disposed of the feces safely, with 14% burying
the waste, and 4% using toilets or pit latrines. Approximately 50% of households reported
having a motorcycle, 21% had bicycles, 30% owned
Table 3: Water source and sanitation facilities two-wheeled tractors, and 4% had a four-wheeled
tractor and 3% had a car, van or truck (Figure 4).
Water and sanitation Distribution
10 Water source
Piped water 0.7%
About 30% of households reported having a mobile
phone. There was a strong relationship between
educational attainment of household head and
economic status, the latter estimated by means of
Protected well 34%
an asset index. Household heads had no education
Unprotected well 18% in 58.3% of households in the bottom economic
Spring water 16% quintile, whereas the head in only 19.6% of
households in the top economic quintile reported
Rain water 0.4%
having no education (Table 4).
Surface water 28%
Proportion of households owning assets
Bottled water 3%
Sanitation Facilities
.5
Flush toilet 22%
.4
Proportion
Pit latrine 1%
.3
No toilet 77%
.2
.1
Most (83%) households had a specific place where
0
household members usually wash their hands.
r
r
cle
e
le
r
Ca
to
on
to
yc
cy
ac
ac
ph
oc
Bi
Tr
Almost all (94%) respondents reported washing
Tr
ot
ile
el
el
M
he
ob
he
r-W
M
W
their hands before eating but only 50% did so before
o-
u
Tw
Fo
cooking, and only 9.3% did so before feeding the Source: CNP Baseline Survey
baby. Furthermore, only 20% of respondents reported
Figure 4: Selected asset ownership
14
Access to improved drinking water sources is defined as year-round access to water from a piped source, protected well, rain water, and/
or bottled water.
Table 4: Distribution of household head’s educational attainment by economic status
Economic quintile Educational attainment of household head
No education Primary Lower secondary Upper secondary Post-secondary Total
and higher
Poorest 58.3% 30.5% 3.5% 5.2% 2.5% 100%
Second 38.4% 41.9% 6.9% 5.8% 7.1% 100%
Middle 32.3% 42.7% 6.7% 9.7% 8.7% 100%
Fourth 31.2% 41.6% 11.3% 8.1% 7.7% 100%
Richest 19.6% 42.0% 16.8% 13.0% 8.6% 100%
In terms of access to health services, the mean households had better access to health facilities as
distance to a health center for households in the compared to households in rural areas without access
sample was 5.5 km, and the mean distance to the to a road (Table 5). Respondents generally reported
closest hospital (provincial or district) was 34.1 km. a very positive perception of the quality of care
Households reported taking approximately 35 received at health centers. More than 40% of
minutes to reach a health center during dry months, respondents described the quality of their health
and almost double that time during the rainy season center as “excellent”, with most of the remaining
(Table 5). The average time to a hospital was 1 hour describing it as “good” (30%) or “okay” (22%). Only 3%
and 42 minutes during the dry months and almost described HCs as “not very good” or “bad”, and 5% did
3 hours during the rainy season. As expected, urban not know or refused to answer.
Table 5: Distance and time to nearest health facility
Distance and time to nearest health facility
Health center Hospital
11
Residence Distance Time Time Distance Time Time
(dry season) (rainy season) (dry season) (rainy season)
Urban 3.0 km 0.3 hrs 0.4 hrs 23.5 km 0.6 hrs 0.8 hrs
Rural with road 5.2 km 0.4 hrs 0.8 hrs 34.5 km 1.6 hrs 2.6 hrs
Rural without road 7.0 km 0.9 hrs 1.7 hrs 39.0 km 2.3 hrs 4.2 hrs
All 5.5 km 0.6 hrs 1.1 hrs 34.1 km 1.7 hrs 2.8 hrs
GENERAL DIETARY AND
HEALTH-RELATED INDICATORS
Respondents reported a diet heavy in grains, and Many women and children were not consuming
were largely self-sufficient in the main foods eaten. essential micronutrients. Only 69% of respondents
The survey asked a number of questions related to reported a diet rich in Vitamin A, and only 55% report-
household dietary diversity. Specifically, respondents ed consuming foods rich in iron. Dietary habits were
were asked to report on consumption of twelve not clearly associated with the ethnicity of the family,
broad food groups in the 24 hours prior to the sur- although there was a notable trend toward higher
vey. While most families consumed grains (98%) and dietary diversity with increasing education of the
vegetables (92%), the percentage of families who ate head of the household, as well as with wealth. For
fruits (32%) was much lower, as was the proportion example, 57% of households in the lowest quintile
eating red meat (43%) or fish (46%). On average, fami- reported a diet rich in Vitamin A compared with 67%
lies ate from four to five of the available categories. among the highest quintile. Likewise, only 40% of
Table 6 provides an overview of what families were respondents in the lowest quintile reported a diet rich
consuming, as well as what types of foods were in iron compared with 64% for the highest quintile.
self-produced and which were purchased.
More than 68% of households reported that there
Table 6: Household dietary diversity had been one or more shocks causing a large
negative impact on living conditions in the two
Type of Food Number of Proportion
families who years prior to the survey. A health shock – involving
consumed purchased the serious illness, injury or death of any member of
this food
that household – affected 26% of all households in
Grains 98% 13% the two years prior to the survey. Weather-related
12 Roots and Tubers
Vegetables
28%
92%
4.8%
2.9%
shocks (drought, floods, mudslides, or strong winds)
affected 42%, and livestock or crop diseases affected
Fruits 32% 27% 35% of all households in the two years prior to the
Red or White Meat 43% 24% survey.
Eggs 12% 62%
The burden of sickness and injury is significant,
Fish 46% 17%
with more than 77% of households reporting
Legumes, Nuts or Seeds 2.6% 63%
that someone in the household had been sick or
Dairy or Insects 19% 99%
injured in the last three months, and just under
Oils or Fats 11% 86% half (42%) of these cases being serious or somewhat
Sugar or Honey 15% 96% serious. Advice or treatment was sought in 75% of
Coffee, Tea, Alcohol 58% 96% cases. This typically involved going to a health center
Total 100% 100% (57%), district hospital (25%) or seeing the village
health volunteer (16%) as detailed in Figure 5.
Where help was wanted but not sought, reasons
include physical access barriers (23%) and financial
considerations (20%).
Health Utilization
Health Care Agent Reasons for Not Utilizing
(among those that utilized) (among those that did not utilized)
.8
.8
.6
.6
Proportion
Proportion
.4
.4
.2
.2
0
0
He t H er
in lun l
l H er
ct ar al
Th st
nd
Ce al H er
l H ler
l
h
ed pe e
M ve
e
To ent
sy
Qu er
No lity
n
Pr h V pita
ta
r
lf T icin
g
pe
it
in aci
ly oo The
t
te
on th
oo th
Bu
ed nsi
pi
ea
to ou
la
en
p
a
m
tO
O
O
ai
t os
os
os
or m
Se ed
o
D th C
n
at
T et
cu s E
o
re
d
Ne Ex
G
Do Ph
u
al
cia
ra
c
io
ge istri
He
nt
iti
tG
al
er
lt
ad
ov
To ot S
No
Tr
N
Di
On
lla
o
Vi
Source: CNP Baseline Survey
Figure 5: Utilization among families experiencing a health shock
Less than 4% of households had any form of Table 7: Barriers to seeking treatment among women
health insurance scheme. For those who did, the
main schemes used were the social security scheme
(1.1%) and health equity funds (0.7%). 4% of all house-
Barriers
Getting the money needed for treatment?
(%)
45% 13
holds reported having to borrow for financing a de-
Finding someone to go with you/Not wanting to 39%
livery in the last two years, and 6% reported having to go alone?
borrow to cover the costs of health care for the
respondent or their children. The median amount The distance to the health center or hospital? 31%
borrowed was US$50 (400,000 kip) but a quarter of Means of transportation to the health center or 29%
these were US$125 (1,000,000 kip) or more. About hospital?
45% of these borrowers remain in debt at the time of
Concern there may not be a health worker? 22%
survey, with half of them owing US$50 (400,000 kip)
or more, and a quarter owing US$125 (1,000,000 kip) Getting permission to go? 21%
or more.15
Concern about having to read? 20%
Financial factors were the most-reported con- Concern that the health worker cannot help? 20%
straint to utilization health services by women.
Concern that there are no supplies or drugs? 20%
45% of all women reported that “getting money for
treatment” was a barrier to obtaining medical advice Concern that health worker does not speak your 13%
or treatment. Not wanting to go alone and physical language?
access were additional problems reported. Language Concern that there may not be a female health 13%
and communication concerns were reported by worker?
13% of women. The full list of reported constraints is
summarized in Table 7.
15
According to the most recent Lao Expenditure and Consumption Survey (LECS 2007), households in the survey provinces had an
average monthly consumption of US$251 (2,089,000 LAK).
Respondents scored well in recognizing danger- these are self-report statements, they need to be
ous symptoms, and many noted the appropriate interpreted with caution as they may not correlate
responses to these symptoms. Most respondents with what respondent actually do when such
reported knowing that with high fever and diarrhea, symptoms occur. Responses to health-seeking
one should seek advice from health centers (HCs), attitudes are summarized in Table 8 below.
hospitals, or village health volunteers. However, as
Table 8: Health seeking knowledge and attitudes
Health Issue Survey Question Response (%)
Dengue fever You just learned that your friend’s four-year - Go to health center (61%)
old child is not feeling well. She has a fever, - Go to district hospital (18%)
chills and a headache and isn’t sure it’s just - Go to village health volunteer (12%)
a minor illness or if it could be dengue fever. - Self-treatment or traditional treatment (3.3%)
What would you advise her to do FIRST?
Diarrhea You just learned that your friend’s two-year - Go to health center (60%)
old son has diarrhea that has lasted for a few - Go to district hospital (17%)
days. She wants to know what she should do. - Go to village health volunteer (12%)
What would you advise her to do FIRST? - Self-treatment or traditional treatment (4.2%)
Diarrhea warning symptoms* Children often get diarrhea. Can you tell me - Ongoing vomiting (53%)
what signs indicate diarrhea so dangerous - Blood/mucous in stool (dysentery) (30%)
that medical attention is required? - Pass watery stools 10 times a day (19%)
- Fever (16%)
- Unable to eat or drink (10%)
- Child not better in three days (3.9%)
14 Diarrhea treatment* What should you do to care for diarrhea at
home? (for normal cases)
- Traditional treatment (39%)
- Give ORS (29%)
- Give medicine (25%)
- Increase fluid intake (10%)
- Don’t know (7.7%)
- Watch for dangerous signs (6.1%)
- Continue feeding as normal (2.9%)
- Reduce fluid intake (0.25%)
Severe illness warning symptoms* Sometimes children have severe illnesses - Child develops fever (61%)
and should be taken immediately to a health - Child becomes sicker (46%)
center or hospital. What types of symptoms - Child has diarrhea and vomiting (44%)
would cause you to take your child to a - Child has cough/cold (32%)
health center or hospital right away? - Child as difficult breathing (5.7%)
- Child has blood in stool (3.2%)
- Child has fast breathing (3.1%)
- Child not able to drink/breastfeed (2.3%)
- Child is drinking poorly (0.48%)
Pregnancy warning symptoms* What are the dangerous signs that you know? - Pain in abdomen (39%)
- Don’t know (35%)
- Strong headache/blurred vision (30%)
- Fever (12%)
- Swollen limbs (8.1%)
- Decrease in fetal movement (4.9%)
- Vaginal bleeding (3.3%)
- Water breaking (0.48%)
*Multiple responses allowed
More than three-fourths of respondents Table 10: Health education by source (last 6 months)
reported having received health information on
Source of information (%)
immunizations, insecticide-treated bed nets,
and hand washing. Far fewer reported receiving Health staff at health center? 81%
information regarding growth monitoring, treatment
Village Health Volunteer? 70%
of tuberculosis, respiratory infections, HIV/AIDS, or
the importance of iron or folate for pregnant women. Village Chief? 68%
The primary sources of health messages were from
Outreach health worker during community visits? 61%
HCs (81%), village health volunteers (70%), and
village chiefs (68%). Table 9 and Table 10 summarize Friends/relatives? 54%
these findings.
Doctor/nurse in hospital? 38%
Table 9: Health education by topic (last 6 months) Lao Women’s Union? 30%
Have you heard the following health message (%) Radio? 22%
in the last 6 months?
Television? 18%
Bringing your children for immunization? 90%
Traditional Birth Attendant (TBA)? 16%
Sleeping in a mosquito net soaked with mosquito 81%
repellant? Pharmacist? 13%
Washing hands? 78% Village PA system? 10%
Using clean water? 73% Traditional Healer? 9%
How to prevent or treat diarrhea? 63% Newspapers? 3%
The benefits of having children take Vitamin A?
Maintaining a sanitary toilet?
54%
47%
Doctor/nurse at clinic?
Monk/Nun?
2%
2%
15
Good ways to nourish children 45%
Given this background on household
Using iodized salt? 45% characteristics as well as general diet- and health
Monitoring your child’s height and weight? 39% -related indicators, subsequent subsections
report findings with regard to key MCH and
How to prevent or treat tuberculosis? 38% nutrition-related indicators.
How to prevent or treat respiratory infection? 32%
How to prevent or treat HIV/AIDS? 31%
Women, especially when pregnant, taking iron 27%
or folate?
MATERNAL HEALTH Table 11: Percent reporting at least one ANC visit
during last pregnancy
The survey asked mothers that had a child in the
Antenatal care (%)
two years prior to the time of survey to provide
information on key aspects of their antenatal, Residence
delivery, and postnatal periods for their most Urban 58.5%
recent pregnancy. Findings from the survey
Rural with road 43.6%
responses related to maternal health are summarized
below. Rural without road 25.4%
Age of mother
Fertility and Contraception Less than 20 36.3%
Women had, on average, given birth 3.3 times 20-34 years 41.5%
prior to the survey.16 Approximately half of women 35-49 years 34.7%
reported having ever used family planning to try to
Mother’s education
prevent pregnancy, with injections (42.8%) and the
pill (40.3%) being the two most popular methods. None 29.1%
Primary 43.9%
Antenatal Period Lower secondary 68.1%
Upper secondary 68.7%
Only about 40% of women reported at least
one antenatal care (ANC) visit during their most Post-secondary and higher 58.2%
recent pregnancy. ANC visits were significantly Economic quintile
higher among urban residents, those mothers that
16 had secondary education and higher, those from
richer households, and those belonging to the Lao-Tai
Poorest
Second
22.8%
26.2%
ethnic group (Table 11).17 ANC utilization rates were Middle 38.9%
particularly low among Mon-Khmer and Hmong-Mien
Fourth 48.3%
ethnic group households, and among poorer
households and households where the mother had Richest 64.1%
received no formal education. Ethno-linguistic group of household head
Lao-Tai 54.0%
Mon-Khmer 29.0%
Hmong-Mien 10.5%
Other 14.4%
Total 40.0%
16
Although the survey included a module on contraceptive use, the sampling methodology does not permit an adequate estimation of
contraceptive use and fertility. Only households with at least one living child two were included in the survey.
17
The levels of ANC utilization are similar in magnitude to those found by other studies in Lao PDR; For example, Manithip et al (2011)
found that about 51% of women in their sample in Khammouane and Champasack provinces received ANC during their most recent
pregnancy in the past 12 months; See Manithip, C, A Sihavong, K Edin, R Wahlstrom, and H Wessel (2011), “Factors Associated with Antenatal
Care Utilization Among Rural Women in Lao People’s Democratic Republic,” Maternal and Child Health Journal, 15: 1356-1362.
Only about half of those utilizing ANC visits had During ANC visits, the most common services
four or more of the recommended visits. Among received were weighing (82%) and counseling on
those who did not attend an ANC visit, more than early and exclusive breastfeeding (76%). Other
two-thirds reported not doing so because they did common services during ANC included counseling
not perceive having any antenatal problems; 17% did on maternal nutrition (59%), iron distribution (56%),
not utilize because of financial considerations; and blood pressure measurement (50%), family planning
11% because of physical access issues (Table 12).18 counseling (48%), blood tests (23%), and tetanus
Health center staff were the most-frequently reported vaccination (33%). Urine pregnancy tests were
persons seen for ANC care with visits occurring both available at only 20% of HCs, and only 19% of women
at the health center as well as in villages during reported receiving one. Nearly 85% of women re-
outreach services. ported ever receiving at least one tetanus toxoid
(TT) vaccination, and 37% reported having the rec-
Table 12: ANC utilization ommended five or more vaccines required to be
Antenatal care Percent (%)
considered fully immunized. Tetanus vaccination
is an important element of the ANC services and is
Received any ANC 40% commonly documented in the maternal vaccination
Reasons for not receiving ANC card, which 36% of women reported owning
(although the card was seen in only 7.1% of cases).19
No problems 71%
Slightly more than a third (39%) of women utilizing
No money 17% ANC reported having been counseled on danger
Health center too far 11% signs during their visit. Decreased fetal movement
and headache or blurry vision were the most
Person seen for ANC (among those receiving ANC)
commonly discussed issues.
Health staff 93%
Traditional birth attendant
Village health volunteer
3.5%
2.6%
From a supply-side perspective, facility surveys
indicated that basic ANC care services were gen-
erally available in all 38 health centers included
17
Most common locations of ANC in the sample. Most health centers reported
Health center 73% providing weight checks, blood pressure checks,
fundal height, abdomen checks, and fetal heartbeat
In the village 64%
checks. Iron or folate supplements were provided
District hospital 27% in 76% of facilities, however, only 55% provided
Home 11% deworming medicine, and less than 20% provided
hemoglobin or any urine test (Table 13). Furthermore,
Timing of First ANC Visit
15 of the 38 health centers did not have even one
First trimester 31% staff member who had received training in ANC
Second trimester 52% services in the two years prior to the survey, raising
concerns about the quality of ANC services provided.
Third trimester 17%
In spite of intensive national campaigns, only half of
Total number of ANC visits health centers report discussing early and exclusive
1 visit 14% breastfeeding during ANC, and only 55% discussed
2-3 visits 35%
4+ visits 52%
18
Manithip et al (2011) found that that 49% of women not utilizing ANC care in their sample in Lao PDR did so because they felt normal
and did not perceive any antenatal problems and 48% reported difficulty accessing health centers.
19
Within a given pregnancy, a woman is considered immunized if she has had two doses during that pregnancy or at least five doses in
her lifetime.
danger signs.20 Although most health centers report Table 14: Assistance at delivery
discussing maternal nutrition and self-care, many
miss the opportunity to discuss birth and emergency Assistance at delivery Percent (%)
planning and the need for follow-up care. About 20% None 55%
of all mothers reported practicing food restrictions Traditional birth attendant 22%
during their last pregnancy, the proportion being
Health staff 18%
the same whether or not they had received any ANC
care. Village health volunteer 4%
Traditional healer 0.30%
Table 13: Provision of ANC services at health Total 100%
centers
Provision of ANC service Percent (%) Only 14% of births among surveyed women
took place at health facilities (Figure 6). While
Is the following ANC service provided? national trends suggest that facility-based delivery is
Fundal height 95% increasing in prevalence, it remains relatively rare
Abdomen check 95% in our sample. Traditions surrounding delivery vary
substantially around the country. In some rural
Fetal heartbeat check 95% communities, child birth is traditionally conducted
Other physical exam 92% in a forested area outside of the village, while other
Weight check 87% communities build separate birthing structures
which are used only once. Home births remain the
Blood pressure check 87% most common location of delivery, even in relatively
Iron or folate 76% more developed areas of the country. More women
Any Tetanus toxoid 66% reported delivering in birth structures or in the
18 Deworming 55%
village than did at the health center, and all
facility-based deliveries (including health centers,
Any urine test 18% district hospitals, and provincial hospitals) accounted
Hemoglobin test 11% for only 14% of deliveries. Reasons for delivering
outside of health facilities included convenience
(43%), tradition (22%), and a lack of money (10%).21
Deliveries Place of delivery
80
Only 18% of births among surveyed women were
attended by skilled birth attendants. With 22% of
60
Percentage (%)
women seeking the assistance of a traditional birth
40
attendant (TBA), these local resources seem to assist
somewhat more frequently than the formal health
20
sector, who were reported to be present in only 18%
of deliveries (Table 14).
0
e
ge
er
l
l
r
ta
ita
he
m
nt
pi
lla
sp
Ho
Ot
ce
os
vi
ho
e/
th
th
ur
e
al
ric
nc
ct
He
st
i
ru
ov
Di
st
Pr
hrt
Bi
Source: CNP Baseline Survey
Figure 6: Place of delivery
20
A study of four district hospitals and 18 health centers in Khammouane and Champasack provinces by Manithip et al (2012) found that
the average encounter time for an ANC visit was very brief (only about 5 minutes) and of poor quality; See Manithip, C, K Edin, A Sihavong,
R Wahlstrom, and H Wessel (2012), “Poor Quality of Antenatal Care Services – Is Lack of Competence and Support the Reason?” Midwifery,
doi:10.1016/j.midw.2011.12.010.
21
Convenience, cost, comfort, and tradition were the reasons cited for not using health facilities for deliveries in a qualitative study of rural
Laotians; See Sychareun, V, V Hansana, V Somphet, S Xayavong, A Phengsavanh, and R Popenoe (2012), “Reasons Rural Laotians Choose
Home Deliveries over Delivery at Health Facilities: A Qualitative Study,” BMC Pregnancy and Childbirth, 12: 86 doi:10.1186/1471-2393-12-86.
As with ANC, there are clear socio-economic More than a quarter (28%) of responding mothers
gradients with regard to skilled birth attendance reported giving birth to a child who later died.
and institutional delivery rates. Both skilled birth Consistent with global patterns, the majority of
and institutional delivery rates were four to five deaths occurred in the first several months of life
times higher among those women who had received and 78% of these children died within the first year
ANC during their latest pregnancy (Table 15). Village of birth. More than a third of mothers did not know
remoteness was a key factor with those in rural the cause of death for their child; among those that
villages without road access having very low skilled knew, fever and diarrhea were among the leading
birth attendance and institutional delivery rates causes (Table 16).
as was maternal education and economic status.
Lao-Tai ethnic group households had higher rates Table 16: Cause of child death
compared with those from other ethno-linguistic Leading Causes of Death Among Children (%)
groups (Table 15).
Fever (excluding Malaria & Dengue) 26%
Table 15: Skilled birth and institutional Diarrhea 9.2%
delivery rates Dengue 5.3%
Respiratory infection 2.7%
Skilled birth Institutional Malaria 2.0%
attendance deliveries Accident 1.2%
(%) (%) Other 17%
Received any ANC Unknown 37%
No 7.5% 6.3% Total 100%
Yes 34.5% 26.0%
Residence
Urban 37.0% 30.3% From a supply-side perspective, most (87%) of
Rural with road 18.2% 14.0%
health centers in the sample provided some
Rural without road
Age of mother
Less than 20
8.6%
24.1%
6.0%
20.9%
delivery services for pregnant women; however,
the range of delivery services was generally 19
20-34 years 18.3% 13.5% limited. Among those health centers providing
35-49 years 13.3% 12.6% delivery services, many lacked capacity to actively
Mother’s education
manage the third stage of labor. Only 24% had
None 10.3% 7.2%
Primary 20.1% 16.8% partographs, and just under half offered oxytocin,
Lower secondary 41.7% 30.2% injectable antibiotics, or neonatal resuscitation.
Upper secondary 40.1% 29.8% Magnesium sulfate is still rare in rural Lao PDR, and
Post-secondary and higher 34.0% 31.9% was available at only 17% of the health centers
Economic quintile
surveyed (Table 17). Of the 33 health centers provid-
Poorest 6.0% 4.6%
Second 12.7% 9.7% ing delivery services, 29 (88%) offer these services
Middle 14.7% 8.4% during evenings and weekends.
Fourth 20.5% 15.6%
Richest 37.3% 32.9% Table 17: Delivery service availability at health
Ethno-linguistic group of household head centers
Lao-Tai 26.3% 21.5%
Mon-Khmer 11.0% 7.7% Are the following delivery services available? Percent (%)
Hmong-Mien 16.3% 11.7% Any 87%
Other 1.9% 1.5% Among those who provide any services:
Total 18.2% 14.2% Partograph 24%
Injectable antibiotics 45%
Oxytocin 42%
Magnesium sulfate 17%
Neonatal resuscitation (with mask and bag) 45%
Postnatal Period Food taboos were very prevalent during the
postnatal period, and were reported by 76% of
Post-natal care (PNC) check-ups within one week women. Meats were very commonly avoided, with
of delivery were rare, and were reported by only 77% of women avoiding buffalo meat and 63% of
2% of women.22 The most common reasons for not women avoiding beef. 58% of women had returned to
seeking PNC included not having any problems their normal diet within one month of delivery, while
(75%), no money (11%), inability due to the 24% restricted their diets for more than six months.
post-delivery “roasting” period (8%), and the distance
from the health center (5%). Almost all women (99%) reported ever
breastfeeding their child, with 40% of all women
initiating breastfeeding within one hour of
delivery. However, about 40% reported waiting
1-3 days before breastfeeding, and nearly half 49%
fed the infant something prior to breastfeeding.
Three-quarters of women reported giving their child
colostrum. Among those who delayed breastfeeding,
77% had no milk, while an additional 19% reported
that the child would not suck.
CHILD HEALTH & NUTRITION
Well-baby and routine check-ups for children under
two were reported by only 8.9% of households in
the survey. Well-baby visits that did take place were
20 generally provided through outreach (55%); 33%
took place at the health center and 15% were at a
hospital.
Immunizations
Only one-quarter (26%) children aged 12-23
months have received all of the vaccines included
in the standardized Expanded Program on
Immunizations (EPI) and one in ten children
aged 12-23 months have not received any
vaccinations at all. This data was obtained from a
combination of vaccination cards (in the 30% of cases
where vaccination cards were available) and verbal
recall. The percentage of children aged 12-23
(i.e. those who are old enough to be fully vaccinated)
months who have been immunized are summarized
in Table 18
Photo by Bart Verweij/2013
22
The low levels of PNC check-ups may be a result of the way in which the question was asked as PNC check-ups may have occurred during
the same time as deliveries occurred and not as separate visits.
Table 18: Vaccination rates among children 12-23 Consistent with national policy emphasizing
months of age quarterly outreach visits, most children are
vaccinated in the village through outreach.
Vaccine Vaccination Card Mother’s Report Either
According to the survey respondents, vaccines were
BCG 28% 56% 84%
DPT1 28% 54% 83% mainly provided in villages (78%), although health
DPT2 25% 15% 41% centers (16%) and hospitals (5%) were also important
DPT3 22% 20% 42% venues for the delivery of vaccinations. This trend
Polio 1 27% 56% 83% was even more prominent when limiting the analysis
Polio 2 27% 18% 45%
to fully immunized children; among these children,
Polio 3 21% 20% 41%
Measles 15% 37% 51% an even higher proportion of vaccinations being
All 14% 12% 26% delivered in villages (83%) at the expense of hospitals
None 0.0% 11% 11% (1.4%). The role of health centers is unchanged at
HepB 9.3% 0.0% 9.3% 16%.
Micronutrient Vaccination Card Mother’s Report Either
Vitamin A 19% 56% 75%
Child Illnesses
While nearly 90% of children receive at least one More than a third of children less than two years
vaccination, the data suggest substantial loss to of age had a fever in the two weeks prior to the
follow-up. Mothers reported many reasons for not survey; 24% had had a cough and 15% had had
fully vaccinating their children, with a lack of time or diarrhea. Among children with a cough, fast breath-
knowledge about the vaccination event being the ing was noted in 64% of cases, which was attributed
most common. Table 19 provides a summary of the to a blocked or runny nose (75%), problems inside
reasons given. the chest (11%), or both (14%). Children were most
likely to receive treatment for fever (65%, compared
Table 19: Reasons for not receiving all vaccinations
(multiple possible)
49% of children with a cough and 63% of children
with diarrhea). Treatment patterns were similar
across the three illnesses, with the health center most
21
Reason (%)
commonly sought for advice, followed by village
Not notified 25%
No time 17% health volunteers, district hospitals and pharmacies
Makes baby sick 6.0% in that order, regardless of illness type (Table 20). For
Baby gets fussy 2.1% fevers, caretakers typically waited until the day after
Not useful 1.1% the onset of the illness to seek advice or treatment
Afraid it is harmful 1.0%
illness; 32% seek care on the same day, and 97%
Expensive 0.5%
Other 10% seeking care within three days of the onset of illness.
The pattern was similar for coughs, with 33% seeking
care on the same day, and 96% seeking care within
three days of the onset of illness.
Table 20: Treatment patterns for childhood illnesses
Illness Incidence in the Any Health Village District Pharmacy Health staff Health staff Friends/
last two weeks treatment center health hospital (outside (at village) family
volunteer village)
Fever 39% 65% 52% 23% 11% 9.3% 6.3% 2.3% 1.6%
Cough 24% 49% 55% 16% 11% 11% 9.1% 6.4% 1.4%
Diarrhea 14% 63% 46% 29% 12% 6.0% -- -- 2.2%
Most children ill with a fever (82%) were given a water sources did not correlate with diarrhea
drug during the illness, most frequently on the prevalence in the sample. Approximately two-thirds
same day (43%), the next day (26%) or two days of children with diarrhea received ORS. During the
after the fever (20%). Relatively few respondents episode of diarrhea, approximately 29% of children
were aware of the treatments given to their children; were given about the same amount of fluids, with
77% of drugs given for febrile episodes unspecified. 0.1% given none, 10% given much less and 28%
Among children who were sick the two weeks before given somewhat less to drink. Only 33% were given
the survey, and 31% were still sick with a fever, 39% more liquids. Fluids given included a form of ORS in
still had a cough. Drugs were somewhat less likely 66% of cases, reconstituted from a “special packed
to be given for a cough (70%). Treatment times were called ORS” (47%), or a government-recommended
similar, with treatment most frequently initiated on homemade fluid (22%), or a pre-packaged ORS liquid
the same day (45%), the next day (20%) or two days (18%).
after the cough appeared (21%). The most common
drug used is cough medicine (69%) followed by Table 22: Diarrhea prevalence among children less
paracetamol (38%) (Table 21). None of the children than two years of age
sick with a cough (n=238) were reported to receive
antibiotics. Diarrhea prevalence two weeks prior to survey Percent (%)
Residence
Table 21: Treatment regimens for ill children Urban 8.7%
Rural with road 17.6%
Treatment (%)
Rural without road 15.3%
Fever Sanitation
Paracetamol 39% No toilet 16.6%
22
Antimalarials 3.2% Flush toilet/pit latrine 8.8%
Antibiotics 1.7% Hygiene
No designated handwashing area 18.3%
Unspecified 77%
Designated handwashing area with soap/ash 13.9%
Cough
Water source
Cough Medicine 69%
No access to improved water source 15.2%
Paracetamol 38% Access to improved water source 15.1%
Total 15.2%
The prevalence of diarrhea among children under
two in rural areas was double that in urban
households. Not unexpectedly, diarrhea rates were
significantly higher in households that lacked or did
not use a flush toilet/pit latrine and in households
that lacked a designated place and did not have soap/
ash for handwashing (Table 22). Access to improved
Anthropometrics
Anthropometric data confirms the high rates of
undernutrition among children under two years
of age. Almost one-third (31%) of children under
two were underweight while more than one-tenth
(11%) were severely underweight.23 The prevalence
of stunting was even more extreme, with 36% of the
same population stunted and 13% severely stunted.
Wasting was also prevalent: 14% of children less
than two were wasted, and 2.9% severely wasted.
These parameters of malnutrition generally worsen
with increasing age: for example, the prevalence of
stunting increases from 22% among children aged
0–5 months, to 50% among children those aged
11–23 months, highlighting the importance of
interventions aimed at adoption of appropriate
complementary feeding patterns at the right times.
Malnutrition rates were substantially higher among
males than females. For example, the prevalence of
underweight was 35% among males and 27% for
females. Likewise, the prevalence of stunting was
40% among male children versus 27% among female
children.
Undernutrition was significantly higher among
rural, socio-economicaly marginalized house-
23
holds lacking access to basic infrastructure. Malnu-
trition rates were much higher among those in rural
areas, those without access to toilet, and in house-
holds where the mother was older and less educated.
Some of the highest malnutrition prevalence rates
were observed among households that were in the
lower economic quintiles. Households headed by the
Mon-Khmer and Hmong-Mien ethnic groups also
tended to have higher rates of malnutrition among
children less than two years of age.
Photo by Bart Verweij/2013
23
Underweight and stunting areas defined as two standard deviations below the median of the WHO Child Growth Standards adopted in
2006; severely underweight and severely stunted are defined as three standard deviations below the same.
Table 23: Malnutrition prevalence among children less than two years of age24
Malnutrition prevalence Underweight (%) Stunted (%) Wasted (%)
Residence
Urban 21.3% 26.7% 12.7%
Rural with road 39.7% 40.4% 14.4%
Rural without road 31.3% 35.7% 13.4%
Sanitation
No toilet 37.5% 39.1% 15.6%
Flush toilet/pit latrine 18.7% 26.2% 8.4%
Hygiene
No designated handwashing area 33.8% 35.7% 16.1%
Designated handwashing area with soap/ash 27.5% 32.7% 9.3%
Water source
No access to improved water source 35.6% 38.5% 14.1%
Access to improved water source 29.8% 32.6% 13.0%
Age of mother
Less than 20 23.5% 36.2% 9.8%
20-34 years 33.8% 36.0% 14.2%
35-49 years 38.9% 37.8% 14.0%
Mother’s education
None 40.5% 42.8% 15.4%
Primary 28.1% 31.4% 12.8%
24 Lower secondary
Upper secondary
23.4%
21.6%
22.9%
26.8%
12.3%
11.2%
Post-secondary and higher 21.9% 30.0% 7.1%
Economic quintile
Poorest 42.7% 42.6% 17.0%
Second 38.8% 41.4% 17.1%
Middle 34.9% 39.0% 12.1%
Fourth 29.4% 33.9% 11.9%
Richest 20.9% 24.2% 10.1%
Ethno-linguistic group of household head
Lao-Tai 24.5% 29.1% 11.0%
Mon-Khmer 43.9% 43.4% 16.9%
Hmong-Mien 15.0% 39.7% 12.7%
Other 21.3% 33.3% 3.3%
Total 33.4% 36.3% 13.8%
24
The table reports household-level prevalence of malnutrition, i.e., it reports the percentage of households that had at least one child
under the age of two that was malnourished. Wasting, which is associated with greater child mortality, is less prevalent than either
underweight or stunting, suggesting a dominance of chronic undernourishment rather than acute undernourishment.
SUMMARY & POLICY trition, with over a third of all children less than two
years of age being underweight or stunted. One
IMPLICATIONS consistent finding relates to the socio-economic
gradients in key MCH and nutrition-related
This report has presented results from a indicators. Across the board, those living in rural,
household survey on MCH & nutrition in mostly remote communities, poorer households, households
rural areas of six central and southern provinces of headed by non-Lao-Tai ethnic groups, and those
Lao PDR. The information is complemented in some wherein the mothers were not educated tended
places with data collected at health facilities. Survey to have some of the worst MCH and nutrition
results confirm and complement existing information
outcomes.
from other sources (such as the LSIS and MICS3) on
the state of MCH- and nutrition-related output and
Service utilization rates remain exceedingly low,
outcome indicators in the country. In addition, the
far lower than rates observed in comparable
survey sheds new light on some of the health risks
countries. The reasons provided by women for the
and challenges faced by the population in central
low levels of ANC, institutional deliveries, PNC, and
and southern Lao PDR, especially in rural and remote
well-baby visitation rates indicate that, in addition
areas. On the positive side, the survey documents
to physical and financial barriers, lack of knowledge
important gains in preventive MCH services.
and awareness of the benefits of contacts with the
Coverage of several different vaccines, including
BCG, are approaching or have met coverage targets formal health system in the country is widespread.
of 80%, and coverage of the measles vaccine is now In addition to demand-side considerations, the
slightly over half (up from 35% in 2006). At 40%, ANC findings from the facility audits which complemented
coverage is has increased by 5 percentage points the household surveys highlight some key deficien-
since 2006.25 cies with regard to service readiness, especially with
regard to provision of key MCH services such as
Despite some modest gains in health service
coverage outcomes, the survey results
underscore the fact that MCH- and nutrition-
delivery-related care in the more rural and remote
parts of the country. These findings will be
documented in more detail elsewhere, but are
25
related challenges continue to plague Lao PDR. presented in brief in Box 2 below. The survey
More than a quarter of the mothers interviewed re- makes clear that important constraints continue
ported having at least one child who had died, and to exist in the supply of basic health services. The
more than a quarter of households had at least one complementary system of outreach can be leveraged
serious illness, injury, or death in the two years prior and enhanced in order to expand the coverage of
to the survey. The data suggest that health shocks basic health services, especially to remote areas.
are among the most common (and most expensive) Careful attention will need to be paid to rationalizing
shocks facing rural residents. Additional detailed use of care and institutionalizing a robust referral
analysis of out-of-pocket expenditure related to system as efforts are made to increase service
access to maternal health services based on the utilization. Going forward, a key challenge will be to
same survey is in progress and is expected later in find the right balance of investments in underutilized
2013. Anthropometric measurements of children health facilities vis à vis investments in the referral
confirm recent reports of serious levels of undernu- and outreach systems.
25
Estimates for 2006 are taken from the 2006 Multiple Indicator Cluster Survey (MICS) 3.
Box 2: Facility Audits
The CNP survey included facility and village level offering urine pregnancy tests. Even the most basic
data collection in addition to the household equipment was often lacking: adult scales were
surveys. In all, 38 health centers were visited. At missing in 20% of health centers and stethoscopes
the facilities, data was collected on catchment area were missing in 15%.
details and utilization; staffing, training and
management; infrastructure and equipment; and Following methodology developed by the WHO,
drugs, tests, and supplies. simple indices of facility service readiness were
created by measuring the percentage of key
Facility audits highlight serious gaps in the Lao equipment and drugs available at health centers.
medical supply systems. While a small number of Figure 7 shows the distribution of service readiness
commodities – notably contraceptives, saline, and scores – divided into quintiles – by both location
pain relievers – were routinely available, many (urban, rural with road, and rural without road)
essential supplies were missing in most health and local poverty. These results highlight declines
centers. BCG vaccine, which should be provided in health facility service readiness as one moves
within three days of birth, was available at less than from urban to more remote or to poorer regions.
40% of facilities visited, and infant antibiotics were Complementary analyses suggest that women
available in only approximately 30% of facilities living in the catchment areas of relatively better
surveyed. Diagnostic capacity was nearly non- resourced health facilities are nearly two times
existent in the health centers visited, with only 40% as likely to utilize ANC services as those in the
of facilities able to provide a malaria test and 20% catchment areas of less resourced facilities.
26 Urban
Service Readiness by Location
Wealthiest
Service Readiness by Catchment Area Poverty
Second Wealthiest
Rural with Road Middle
Next to poorest
Rural no Road
Poorest
0 20 40 60 80 100 0 20 40 60 80 100
percent percent
Lowest quintile Second quintile Lowest quintile Second quintile
Middle quintile Fourth quintile Middle quintile Fourth quintile
Highest quintile Highest quintile
Figure 7: Health center service readiness scores by location and poverty status
Increasing uptake of services is of little value if challenges. These results highlight the need to
the services received offer no benefit to patients, invest more in insuring that high-quality services
and serious attempts to increase the utilization of are available when contact is made with the health
services must address these basic supply-side system.
The need for accelerating improvements in MCH- services among the population as a whole, there is a
and nutrition-related outcomes has not gone danger that the policy will exacerbate existing health
unnoticed by the government. Efforts aimed at inequalities if relatively wealthier families – with
increasing uptake of MCH services are steadily better access to health infrastructure and services
gaining momentum in the country, and the – disproportionately utilize the free services. In
government has committed itself to making key addition, implementation will need to be
MDG-related health services accessible to the complemented by improvements in the capacity
population as part of its new reform agenda. Al- of health facilities, not just in clinical and service
though the planned increases in government health availability terms, but also in terms of their ability to
spending are welcome, challenges remain. These manage and allocate revenues appropriately. Current
include ensuring that the additional resources are weaknesses include inconsistent implementation
used to improve access to and quality of health of user fee regulations and revenue management,
services – especially in more remote areas – and variation in management practices, weak
progressively making additional domestically- procurement practices for drugs, and inadequate
financed resources available to reduce both service provision levels.
dependence on external funding and out-of-pocket
spending for health. To attain these objectives, It is important to note that the planned removal
the government should consider an appropriate mix of user fees, as envisioned under the free MCH
of both demand-side and supply-side incentives. policy, may not be sufficient to improve utilization
Instead of, or in addition to, setting a target for and inequalities across the country. To achieve
budgetary outlays for health, the government needs this, the government should consider additional
to improve the efficiency of existing outlays, the supply-side and community-focused demand-side
measurement of which requires the monitoring of interventions, especially in rural areas building
key population health outputs. These should include on the lessons of the Ministry of Health’s pilot
focus on the level and equity of basic immunization
rates, of skilled birth attendance, of institutional
delivery rates, of need-based outpatient and
Community Nutrition Project. If successful, the free
MCH policy is likely to have its greatest impact on
facility-based delivery rates. Alternative strategies
27
inpatient utilization rates, and on adequate levels of will likely be needed to increase utilization of
financial protection from adverse health shocks. antenatal care, postnatal care, or vaccination, as each
of these service categories are officially free of charge
The planned implementation of the free MCH and have been so for decades. Strategies aimed at
policy, which will be implemented to scale this increasing coverage of these interventions should
year, is a welcome step in the right direction. This focus on a combination of demand-side interven-
policy seeks to remove user fees at the point of service tions, aimed at behavior change and education
for key MCH services and to provide utilization-based campaigns, and supply-side interventions aimed
reimbursements to health facilities. Notably, the at improving the quality of services that are
proposed package of services included in the delivered. One potentially important supply-side
free MCH Policy includes facility-based delivery. intervention is the expansion and improvement
Experience from a recent World Bank-funded pilot of integrated outreach. During routine outreach,
eliminating user fees suggests that this policy may health workers visit villages in their catchment
offer important gains in this area. A two-year World areas to provide free-of-charge vaccination services,
Bank-funded project piloted free deliveries in two ANC, and PNC and some limited curative care.
districts in the same region. It found that facility While these visits remain an important point of
based deliveries increased by 300% in the districts care for many living in rural areas, there is evidence
in which user fees were eliminated; this compares that these visits are not currently offering access
to a much smaller 40% increase in neighboring to a basic package of services. Although outreach
control health districts. However, implementation of guidelines provided by the Ministry of Health
the policy must be carefully monitored. As with all stipulate that several antenatal and postnatal
such strategies aimed at increasing the utilization of services be available at outreach, the survey results
suggest that less than 5% of ANC visits took place in
the village.
Improving nutrition outcomes poses a particular the survey finds a strong correlation of diarrhea
policy challenge in the country. Poor nutritional incidence and improved facilities. Table 23 highlights
outcomes in Lao PDR have complex causes. Food a consistent decrease in diarrheal incidence with the
insecurity remains a problem. However, the issue goes increase in the local availability of flush toilets. The
beyond a shortage of food. Malnutrition is caused by National Nutrition Strategy (NNS) was released
inappropriate breastfeeding and complementary in 2009, and followed up with a National Plan of
feeding practices, food taboos associated with preg- Action for Nutrition (NPAN) the same year.
nancy and the postpartum period, high incidence Together, the NPAN and NNS have helped to create a
of vector and food-borne disease, and myriad other motivated coalition of actors seeking progress on
factors. Many of these causes are only weakly what has been an especially intransigent challenge
related to the availability of and access to food, as is in Lao PDR. Fifteen ministries and organizations are
evidenced by the relatively high rates of malnutrition held to be accountable for nutrition outcomes and,
observed even in better-off segments of the following the release of the NPAN, government
population. According to an earlier World Bank- and development partners rallied around the issue.
supported study of infant and young child feeding However, implementation of the plan has been slow
in Lao PDR, there remains a widespread belief in Lao and better prioritization of critical interventions
PDR that young children know when and how much is needed. The existing NPAN contains 44 priority
to eat; this results in the absence of engaged and in- interventions requiring immediate action, and
teractive feeding behavior, and low overall quantity of include increasing the coverage of exclusive
dietary intake for vulnerable children. Development breastfeeding and scaling up immunization to
partners such as UNICEF have been supporting the introducing conditional cash transfers for ANC,
Ministry of Health in developing the capacity of the PNC, and deliveries. The annual budget for the 44
Center for Information and Education for Health interventions was estimated at US$25 million: while
(CIEH). Following the successful implementation of a the targeted budget is substantial, there is little
28 national exclusive breastfeeding campaign in 2010,
the center has more recently begun to tackle the
challenge of building a broad engagement with na-
guidance on where the funds should come from
and whether the planned increases in domestically-
sourced government financing would specifically
tional and local stakeholders- including government target these interventions.
agencies, development partners, non-governmental
organizations (NGOs), and civil society organizations The response to nutrition issues will need coordi-
(CSOs) – in order to ensure appropriate and consis- nated action across sectors. Leadership has been
tent messaging. The team has also been active in a challenge in Lao PDR. Even within the national
expanding the availability of materials appropriate health sector, leadership around nutrition is only
in multi-ethnic/multi-language and low literacy recently beginning to arise, and a designated center
environments. for nutrition was only created at the Ministry of Health
in 2012. While the goal of facing this multi-sectoral
Improvements in nutritional outcomes will challenge with a multi-sectoral response was laid out
require a multi-sectoral response aiming to in the Ministry of Health’s NNP, early calls to introduce
educate families on appropriate feeding prac- a coordinating committee at the level of the Cabinet
tices, especially for infants and young chil- – with ties to the Ministries of Health, Education,
dren; increasing access to improved water and Agriculture and others that were initially envisaged
sanitation facilities to reduce the prevalence of to participate – have only recently been initiated.
water, food and vector-borne diseases; and im- Attacking the persistently high levels of malnutrition
proving access to health care services for those in Lao PDR will require a high-level emergency
in need. Consistent with international studies, multi-sectoral policy response.
26
Gillespie, A, H Creed-Kanashiro, D Sirivongsa, D Sayakoumanne, and R Galloway (2004), “Consulting with Caregivers: Using Formative
Research to Improve Maternal and Newborn Care and Infant and Young Child Feeding in the Lao People’s Democratic Republic,” HNP
Working Paper, World Bank, Washington, DC.
ANNEX A: LIST OF SURVEYED HEALTH CENTERS
No Province District Health Center Status27
1 Attapeu Phouvang Nachuak Intervention
2 Attapeu Xaysetha Kengmakeua Intervention
3 Savannakhet Thapangthong Xekeu Intervention
4 Savannakhet Xepon Dongsavanh Control
5 Savannakhet Xepon Phabang Control
6 Savannakhet Xepon Ladhor Intervention
7 Savannakhet Xepon Manchi Intervention
8 Savannakhet Nong Danvilay Intervention
9 Savannakhet Nong Nakong Control
10 Savannakhet Vilabouly Nayom Intervention
11 Savannakhet Phalanxay Nasai Control
12 Salavane Samuoi Amin Control
13 Salavane Samuoi Asok Control
14 Salavane Samuoi Kimae Control
15 Salavane Taoi Tahouark Intervention
16 Salavane Taoi Photang Intervention
17 Salavane Taoi Kokbik Control
18 Salavane Toomlarn Nadou Control
19 Khammouane Nakai Natane Intervention
20 Khammouane Yommalad Hai Control
21
22
Khammouane
Khammouane
Yommalad
Xaybouathong
Phid
Kengchone
Control
Intervention
29
23 Khammouane Xaybouathong Naphao Intervention
24 Khammouane Xaybouathong Nanoithong Control
25 Khammouane Boualapha Sobpheng Control
26 Khammouane Boualapha Sok Control
27 Khammouane Mahaxay Panam Intervention
28 Champasak Sukhuma That Control
29 Champasak Pathoomphone Sanod Control
30 Champasak Pathoomphone Lak 24 Intervention
31 Champasak Bachiang Kuangsy Intervention
32 Champasak Bachiang Kengkia Control
33 Bolikhamxay Khamkheuth Phamoeung Intervention
34 Bolikhamxai Khamkeut Khammuane Control
35 Bolikhamxai Xaychamphone Nam one Control
36 Bolikhamxai Borlikhan Ban Bo Intervention
37 Bolikhamxai Borlikhan Nakoun Intervention
38 Champasak Sukhuma Nachan Intervention
27
The survey was conducted in preparation for the impact evaluation of CNP and matched paired health centers are included in the
survey. Control health centers are not implementing project activities were surveyed together with intervention health centers which
are.
The World Bank Group
The World Bank Lao PDR Country Office
Patouxay Nehru Road
P.O Box: 345
Vientiane, Lao PDR
Tel: (856-21) 266 200
Fax: (856-21) 266 299
Websites: www.worldbank.org/lao
The World Bank
1818 H Street, NW
Washington, D.C. 20433, USA
Tel: (202) 4731000
Fax: (202) 4776391
Website: www.worldbank.org
Photo by Stan Fradelizi/2011